Distributing pharmaceutical products is a complex process involving pharmaceutical product providers, e.g., pharmacies, pharmaceutical drug manufacturers, health insurance plans, pharmacy benefit managers (“PBMs”), and several federal and state governmental agencies. In many instances, PBM's administer pharmacy plans on behalf of insurance plans and/or insurance carriers, negotiate wholesale drug prices for those same plans, and in some cases, negotiate prices to be paid by pharmacies for pharmaceutical products. Pharmaceutical product manufacturers may give price discounts that are taken into account when reconciling payments among and between insurers, PBM's and pharmacies. Government agencies may receive discounts from the manufacturers, while also regulating the reimbursement rates they may pay to a pharmacy.
Pharmacies may file hundreds of thousands of claims with one or more PBMs or insurance carriers for drugs they dispense to a consumer. These claims seek reimbursement at an agreed upon rate for dispensing a drug to a consumer and for accepting a co-pay less than the full price for that drug from the consumer. The administrative burden in filing and adjudicating claims, given the complex interactions discussed above, is substantial. Because of the high volume of claims filed in a given month or year, ensuring that the claims are adjudicated in accordance with the reimbursement contract is not a routine business practice. Unless the claim is adjudicated consistent with the contract rate, the pharmacy may not receive the full monetary benefit of distributing a pharmaceutical to the consumer.
Accordingly there is a need to simplify the process of comparing pharmaceutical contract information to claims.